Rehab First for Degenerative Meniscal Tears

At the turn of the century, arthroscopic surgery was widely used as a first-line treatment for degenerative meniscal tears. However, supervised exercise therapy was first shown to be non-inferior to arthroscopic partial meniscectomy (APM) in 2007.1 Later, several high-quality studies, with follow-ups ranging from two years to five, have found the same conclusion.2 -14 Subsequently, recently updated guidelines recommend a period of non-surgical management for degenerative, non-locking, meniscal tears.15-17 Has the science changed healthcare practices? Over that timeframe, the rates of APM in some countries have not changed appreciably. However, in Australia, the rates of APM for degenerative meniscal tears have declined 40% from 2008 to 2018.18 One matter still unsettled is the degree to which surgery or physiotherapy will limit the progression of future meniscal tearing. Among older patients, studies have associated physiotherapy with fewer degenerative changes and a 5x lower risk of total knee replacement.19,20 On the other hand, other studies have not found appreciable differences in the progression of meniscal tearing.10,13 To add high quality evidence to this evolving discussion, the Journal of the American Medical Association published a new, long-term study from the Netherlands in July.14 The data will certainly help us have evidence-based, collaborative decision making with patients. In the current study, Noorduyn et al. report the 5-year results of randomising 278 patients, age 45 to 70, into APM or physiotherapy groups. Exercise therapy patients received at least sixteen 30-minute physiotherapy visits over eight weeks. The primary outcome was the International Knee Documentation Committee Subjective Knee Form, a 100-point scale where 11 points indicate a clinically significant difference. At multiple time points ranging from 3 to 60 months, APM scored roughly 1 to 6 points better than exercise therapy - never reaching clinical or statical significance. The 95% confidence interval for the difference never went over 11 points, assuring the authors of the conclusion that supervised exercise.

therapy is not inferior to APM, and making rehab the preferred first-line treatment. Nevertheless, both treatments achieved clinically significant improvements (a mean of 27 points on a 100-point scale, with improvements increasing over time). In both groups, roughly half of the patients experienced osteoarthritis (OA) progression. This compares favourably with an earlier study finding that OA progresses in 97% of cases without treatment.21 In the current study, at five years, researchers found symptomatic OA in only four of the surgery patients and two of the physiotherapy patients. Consistent with earlier studies, seven out of ten patients receiving exercise therapy did not elect surgery. A new observation of the current study is that 90% of patients electing delayed surgery made the decision within the first two years. Ninety-five percent of patients who find exercise therapy successful in the first two years do not elect surgery in the following three years.  

References

1. Herrlin S, Hållander M, Wange P, Weidenhielm L, Werner S. Arthroscopic or conservative treatment of degenerative medial meniscal tears: a prospective randomised trial. Knee Surgery, Sports Traumatology, Arthroscopy. 2007 Apr;15(4):393 -401.

2. Kirkley A, Birmingham TB, Litchfield RB, Giffin JR, Willits KR, Wong CJ, Feagan BG, Donner A, Griffin SH, D'Ascanio LM, Pope JE. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. New England Journal of Medicine. 2008 Sep 11;359(11):1097-107.

3. Katz JN, Brophy RH, Chaisson CE, De Chaves L, Cole BJ, Dahm DL, Donnell-Fink LA, Guermazi A, Haas AK, Jones MH, Levy BA. Surgery versus physical therapy for a meniscal tear and osteoarthritis. New England Journal of Medicine. 2013 May 2;368(18):1675-84.

4. Yim JH, Seon JK, Song EK, Choi JI, Kim MC, Lee KB, Seo HY. A comparative study of meniscectomy and nonoperative treatment for degenerative horizontal tears of the medial meniscus. The American Journal of Sports Medicine. 2013 Jul;41 (7):1565-70.

5. Gauffin H, Tagesson S, Meunier A, Magnusson H, Kvist J. Knee arthroscopic surgery is beneficial to middle-aged patients with meniscal symptoms: a prospective, randomised, single-blinded study. Osteoarthritis and Cartilage. 2014 Nov 1;22 (11):1808-16.

6. Kise NJ, Risberg MA, Stensrud S, Ranstam J, Engebretsen L, Roos EM. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. BMJ. 2016 Jul 20;354.

7. Van De Graaf VA, Noorduyn JC, Willigenburg NW, Butter IK, De Gast A, Mol BW, Saris DB, Twisk JW, Poolman RW, ESCAPE Research Group. Effect of early surgery vs physical therapy on knee function among patients with nonobstructive meniscal tears: the ESCAPE randomized clinical trial. JAMA. 2018 Oct 2;320(13):1328-37.

8. Abram SG, Hopewell S, Monk AP, Bayliss LE, Beard DJ, Price AJ. Arthroscopic partial meniscectomy for meniscal tears of the knee: a systematic review and meta-analysis. British Journal of Sports Medicine. 2020 Jun 1;54(11):652-63.

9. Berg B, Roos EM, Englund M, Kise NJ, Tiulpin A, Saarakkala S, Engebretsen L, Eftang CN, Holm I, Risberg MA. Development of osteoarthritis in patients with degenerative meniscal tears treated with exercise therapy or surgery: a randomized controlled trial. Osteoarthritis and Cartilage. 2020 Jul 1;28(7):897-906.

10. Herrlin SV, Wange PO, Lapidus G, Hållander M, Werner S, Weidenhielm L. Is arthroscopic surgery beneficial in treating non-traumatic, degenerative medial meniscal tears? A five year follow-up. Knee Surgery, Sports Traumatology, Arthroscopy. 2013 Feb;21(2):358-64.

11. Katz JN, Shrestha S, Losina E, Jones MH, Marx RG, Mandl LA, Levy BA, MacFarlane LA, Spindler KP, Silva GS, MeTeOR Investigators. Five‐Year Outcome of Operative and Nonoperative Management of Meniscal Tear in Persons Older Than Forty‐Five Years. Arthritis & Rheumatology. 2020 Feb;72(2):273-81.

12. Sihvonen R, Paavola M, Malmivaara A, Itälä A, Joukainen A, Kalske J, Nurmi H, Kumm J, Sillanpää N, Kiekara T, Turkiewicz A. Arthroscopic partial meniscectomy for a degenerative meniscus tear: a 5 year follow-up of the placebo-surgery controlled FIDELITY (Finnish Degenerative Meniscus Lesion Study) trial. British Journal of Sports Medicine. 2020 Nov 1;54 (22):1332-9.

13. Sonesson S, Kvist J, Yakob J, Hedevik H, Gauffin H. Knee arthroscopic surgery in middle-aged patients with meniscal symptoms: a 5-year follow-up of a prospective, randomized study. Orthopaedic Journal of Sports Medicine. 2020 Jan 20;8(1):2325967119893920.

14. Noorduyn JC, van de Graaf VA, Willigenburg NW, Scholten-Peeters GG, Kret EJ, van Dijk RA, Buchbinder R, Hawker GA, Coppieters MW, Poolman RW, ESCAPE Research Group. Effect of physical therapy vs arthroscopic partial meniscectomy in people with degenerative meniscal tears: five-year follow-up of the ESCAPE randomized clinical trial. JAMA Network Open. 2022 Jul 1;5(7):e2220394-.

15. Abram SG, Beard DJ, Price AJ, BASK Meniscal Working Group. Arthroscopic meniscal surgery: a national society treatment guideline and consensus statement. The Bone & Joint Journal. 2019 Jun;101(6):652-9.

16. Van Arkel ER, Koëter S, Rijk PC, Van Tienen TG, Vincken PW, Segers MJ, Van Essen B, Van Melick N, Stegeman BH. Dutch Guideline on Knee Arthroscopy Part 1, the meniscus: a multidisciplinary review by the Dutch Orthopaedic Association. Acta Orthopaedica. 2020 Nov 20;92(1):74-80.

17. Siemieniuk RA, Harris IA, Agoritsas T, Poolman RW, Brignardello-Petersen R, Van de Velde S, Buchbinder R, Englund M, Lytvyn L, Quinlan C, Helsingen L. Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline. BMJ. 2017 May 10;357.

18. Lee SM, Awal W, Vertullo C. Changing practice: incidence of non-reconstructive arthroscopic knee surgery in people over 50 years of age, Australia, 2008-2018. Med J Aust. 2020 Jan 13;212(1):29-30.

19. Katz JN, Shrestha S, Losina E, Jones MH, Marx RG, Mandl LA, Levy BA, MacFarlane LA, Spindler KP, Silva GS, MeTeOR Investigators. Five‐Year Outcome of Operative and Nonoperative Management of Meniscal Tear in Persons Older Than Forty‐Five Years. Arthritis & Rheumatology. 2020 Feb;72(2):273-81.

20. Collins JE, Losina E, Marx RG, Guermazi A, Jarraya M, Jones MH, Levy BA, Mandl LA, Martin SD, Wright RW, Spindler KP. Early Magnetic Resonance Imaging–Based Changes in Patients With Meniscal Tear and Osteoarthritis: Eighteen‐Month Data From a Randomized Controlled Trial of Arthroscopic Partial Meniscectomy Versus Physical Therapy. Arthritis Care & Research. 2020 May;72(5):630-40.

21. Thorstensson CA, Andersson ML, Jönsson H, Saxne T, Petersson IF. Natural course of knee osteoarthritis in middle-aged subjects with knee pain: 12-year follow-up using clinical and radiographic criteria. Annals of the Rheumatic Diseases. 2009 Dec 1;68(12):1890-3